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Some With Depression Able to Get Assisted Suicide

Oregon's 11-year-old assisted-suicide law bars lethal prescriptions for people found to have a mental disorder causing impaired judgment.

Although most terminally ill Oregonians who receive medical aid in dying under the state's assisted-suicide law do not have depressive disorders, some patients with depression did receive a prescription for a lethal drug, researchers found.

The findings by Linda Ganzini, M.D., a professor of psychiatry at Oregon Health and Science University, and her colleagues published October 27 in the online version of BMJ (British Medical Journal) are the most recent of several they have conducted on the state's assisted-suicide law.

The researchers examined 58 Oregonians, most terminally ill with cancer or amyotrophic lateral sclerosis, who either had requested aid in dying from a physician or contacted a right-to-die advocacy organization. A study psychologist administered the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I). Then, a different psychologist reviewed the auddiotapes, interspersed with interviews of terminal patients not requesting aid in dying, and determined that 15 study participants met criteria for depression and 13 met criteria for anxiety disorders.

Although thoughts of death or suicide and suicidal plans or attempts are criteria for major depressive disorder in DSM, the researchers attributed suicidal ideation to a diagnosis of depression only if the patient endorsed suicidal thoughts or plans aside from their interest in pursuing physician-assisted suicide.

By the end of the study, 42 patients had died. Among these, 18 had received a prescription for a lethal drug, and nine had died by lethal ingestion of the prescribed medication. Three lethal-dose recipients met the criteria for depression and died by "legal ingestion," the study authors found.

"Our findings also indicate that the current practice of legalized aid in dying may allow some potentially ineligible patients to receive a prescription for a lethal drug," said Ganzini and her coauthors.

The 11-year-old law authorizes physicians to prescribe a lethal dosage of drugs—usually a short-acting barbiturate—to a competent adult who requests it. Safeguards in the law aim to ensure that patients are adult, competent, terminally ill, and choosing to end life voluntarily but not impulsively.

Oregon's Death With Dignity Act requires the prescribing or consulting physician to refer the requester of a fatal dose to a psychiatrist or psychologist if he or she is concerned that the patient's judgment is impaired by a mental disorder. The law bars prescribing a fatal dose until one of those clinicians determines that the patient does not have a mental disorder causing impaired judgment.

The recent research study comes as the debate continues over the influence of psychiatric illness on an ill person's desire for assisted suicide. "For people at the end of life, depression, hopelessness, and psychosocial distress are among the strongest correlates of a desire for hastened death," Ganzini and colleagues wrote.

Previous research has found that physicians, hospice professionals, and family members of patients who seek assisted suicide in Oregon generally do not believe that major depression was present in most patients who requested assisted suicide. In fact, caretakers never requested psychiatric evaluations for any of the people who died by assisted suicide in Oregon in 2007.

The authors pointed out that previous research has found that "health care professionals" often fail to recognize depression and its impact, particularly among medically ill patients.

A study conducted by Ganzini and colleagues and published in the September 2002 Journal of Pain and Symptom Management found that a feeling of hopelessness—but not a major depressive disorder—at the start of the study predicted a desire for assisted suicide later on. That ran counter to research by William Breitbart, M.D., chief of the psychiatry service at Memorial Sloan-Kettering Cancer Center. That study, published in the December 2000 JAMA, found that hopelessness and depression both contributed to terminally ill patients' desire for a hastened death (Psychiatric News, September 15, 2006).

Among the acknowledged limitations of the recent study was the inability to understand the extent of the impact that depression, even when it had been formally diagnosed, had on the patients' desire to end their lives. The authors said that even the three depressed patients who died by lethal ingestion could have satisfied the requirements of the Death With Dignity Act if the attending physician had determined that depression was present but not influencing their judgment.

"Although diagnosing depression can be relatively straightforward, determining its role in influencing decision making is more difficult, even by expert assessment," wrote Ganzini and colleagues.

A 1996 study published by Ganzini and colleagues in the American Journal of Psychiatry, for example, found that among 321 psychiatrists in Oregon, only 6 percent said they were very confident that a single evaluation would allow them to adequately determine whether a psychiatric disorder was impairing the judgment of a patient requesting assisted suicide.

The finding that some cases of depression in terminally ill patients requesting physician-assisted suicide are missed or overlooked led the study authors to conclude that the Oregon law may not adequately protect mentally ill individuals. They urged "increased vigilance and systematic examination for depression among patients who may access legalized aid in dying."

Future research also is needed, Ganzini and colleagues noted, to help determine the effect of treatment of depression on the choice to hasten death.

An abstract of "Prevalence of Depression and Anxiety in Patients Requesting Physicians' Aid in Dying: Cross-Sectional Survey" is posted at <www.bmj.com/cgi/content/abstract/337/oct07_2/a1682>.

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